Poor Patient Activation Leads to Claim of Negligent Disease Management

Patient activation has a significant effect on a patient’s management of chronic disease.¹ Various studies indicate that promoting discussion and problem solving to help chronic disease patients make informed self-management choices on an ongoing basis increases activation and improves outcomes.²

Allegation

Negligent management of diabetes resulted in renal failure.

Case File

A 47-year-old female patient who was taking insulin and metformin to control her diabetes started treating with a family physician (FP) in 1998. Her blood glucose was 220 (her target range was 70-130); therefore, the FP increased the patient’s metformin and decreased the insulin dose. The FP ordered blood tests, but the patient never had them done. During the next six years, the patient presented only when she had a health complaint. The FP generally ordered blood tests, but the patient never followed through. The FP refilled the patient’s diabetes prescriptions on a regular basis.

In 2004, the patient had her blood tested. Her blood glucose was 280 and HbA1C was 9.3 (her target range was < 7). The FP did not document discussing the abnormal results and did not make any changes to the patient’s medications. Four more years passed.

In April 2008, the patient presented for peripheral numbness in her hands, which the FP attributed to diabetic neuropathy. He prescribed gabapentin and provided the patient with home blood sugar testing supplies. Following the appointment, the patient had her blood tested. Her blood glucose level was 270, BUN was 33 (normal is 7-20 mg/dL) and creatinine was 2.6 (normal is 0.6 to 1.1 mg/dL for women). The FP did not document discussing the abnormal results with the patient.

In May 2009, the patient presented because of a foot infection. In addition to treating the infection, the FP ordered blood tests. The patient, who had become more compliant because her boyfriend was encouraging her to take better care of herself, had her blood tested the next day. Her BUN was 64 and Creatinine was 7.4, prompting the FP to advise her to go to the emergency department (ED). The ED admitting diagnosis was chronic renal insufficiency due to diabetes, azotemia, and renal failure. The patient thereafter required dialysis and was told she would eventually need a kidney transplant. The patient sued the FP, alleging the FP’s failure to monitor her kidney function was below the standard of care and resulted in kidney failure.

Discussion

Experts who reviewed this case could not support the FP’s treatment of the patient because of the long period he prescribed diabetes medications with no baseline labs or information concerning potential adverse effects on the patient’s kidney function. The FP conceded he should have been testing the patient every three to four months due to metformin’s potential nephrotoxicity, and should not have continued to refill the patient’s medications without checking the patient’s kidney function.

In his defense, the FP testified he instructed the patient to make regular appointments and follow up on ordered blood tests, but she failed to do so. The FP also believed he would have talked to the patient about her kidney disease, when her blood tests in 2008 indicated it. However, the patient testified the FP had never suggested a set schedule for appointments. She also denied that the FP regularly ordered blood tests, claimed she was never informed of the risks of nephrotoxicity, and was never told she had kidney disease. Her responses to questions indicated her general ignorance about effective diabetes self-care.

The patient’s side of the story was consistent with the FP’s medical record, which did not indicate efforts to establish regular visits or increase the patient’s adherence to the diabetic regimen. Defense experts conceded that the patient shared responsibility for her outcome, but her inability to be engaged in follow-up and better self-care was facilitated by the FP’s minimalist approach to management.

Medical Liability Risk Management Recommendations

Helping patients play an active role in their own healthcare is a key aspect of patient activation. Consider the following recommendations to gauge and increase activation among patients with chronic disease:^2,3

• Help patients identify their own concerns and challenges about treatment and self-care.
  • Use motivational interviewing techniques such as the American Academy of Family Physicians’ “Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing.”
• Help patients feel comfortable about asking questions.
  • Use “Ask Me 3: Good Questions for Your Good Health,” an Institute for Healthcare Improvement educational program intended to help patients better understand their health.
• If a language barrier exists, offer to provide an interpreter.
• Make adherence with treatment and self-care recommendations easier for low activation patients:
  • Arrange for laboratory tests onsite and on the day of the appointment whenever possible.
  • Have staff meet with less activated patients prior to their appointment to help formulate questions for the clinician and after the appointment to discuss and review medications and other treatment recommendations.
  • When discussing self-care, demonstrate the skill (e.g., monitoring blood sugar, administering insulin, or documenting diet and exercise habits), then watch the patient perform the task to ensure comprehension.
  • Propose self-care improvements in small steps — success is an important aspect of increasing activation level.
• Help patients register for your patient portal, demonstrate it for them, and offer ongoing technical support.
• Monitor patient success with treatment and self-care recommendations.
  • If a patient’s report of adherence is not resulting in improvement, try to determine whether the patient is performing the task incorrectly and provide further training as necessary.
  • Regularly revisit treatment and self-care recommendations and determine if modifications are necessary.
  • Help the patient explore why interventions are not working and how to take action.
    • For example, instead of asking the patient, “Are you exercising?” or “Are you watching your sugar intake?” Ask open-ended questions that cannot be answered with a “yes” or “no” answer, for example, “What have you tried for exercise?” or “What worked?” or “What didn’t work?”
  • Document the patient’s adherence to recommended treatment.
  • Document education given and patient responses regarding self-help recommendations and improvement strategies.

References

1. Remmers C, Hibbard J, Mosen DM, et al. “Is Patient Activation Associated with Future Health Outcomes and Healthcare Utilization Among Patients with Diabetes?” J Ambul Care Manage. 2009;32 (4):320–7. (resource not available online)

2. Hibbard J, Gilburt H. “Supporting People to Manage their Health: An Introduction to Patient Activation.” The King’s Fund. May 2014. (accessed 9/18/2018)

3. De Leon, SF et al. “Effect of Physician Participation in a Multi-Element Health Information and Data Exchange Program on Chronic Illness Medication Adherence.” J Am Board Fam Med. 2015;28(6):742-749. (accessed 9/18/2018)

Linked Sources

Stewart E., PhD, and Fox, C, MD. “Encouraging Patients to Change Unhealthy Behaviors with Motivational Interviewing.” Fam Pract Manag. 2011 May-June;18(3):21-25. (accessed 9/18/2018)

Institute for Healthcare Improvement. “Ask Me 3: Good Questions for Your Good Health.” (accessed 9/18/2018)